ORIGINAL RESEARCH
com
Effect on Post-Operative Pain of Suture Material used for Closure of
Parietal Peritoneum in Caesarean Section
Sharma Avantika1, Hooja Nupur2, Rajoria Lata3, Shastri Apoorv4, Sharma Megha5, Aseri Sapna6
ABSTRACT
Introduction: Caesarean section is the commonest obstetric
surgery and postoperative pain is one of the major discomfort
which drives post caesarean mothers to seek help. The study was
undertaken to study the effect of closure of parietal peritoneum by
Chromic Catgut versus Polyglactin on postoperative pain.
Material and Methods: It was a hospital based interventional
study done in a tertiary care hospital over one year. Detailed
history, investigations, operative details, postoperative outcome in
terms of pain were noted. Unpaired t test and Pearson correlation
coefficient were used for statistical analysis.
Result: Significantly less pain score was observed when
Chromic Catgut was used. This difference was highly significant
statistically at 16 hour (P=0.00005), 24hour (P=0.00001) and 40
hour (P=0.000104) postoperatively.
Conclusion: Peritoneal closure with Chromic Catgut suture is a
better technique than closure in terms of less postoperative pain
and cost saving.
Keywords: Caesarean, Chromic Catgut, Closure, Peritoneum,
Polyglactin, VAS Score
INTRODUCTION
Caesarean section is the commonest and most significant
operative procedure in obstetrics. The global increase in rate
has been due to increase in high risk factors- pregnancy induced
hypertension, diabetes,HIV infections and acute herpes genitalis.
Increased detection of fetal distress, fetal malpresentations and
intrauterine growth restriction have contributed to the increase
in the number of caesarean sections performed.1
Usually the two layers of peritoneum are sutured again in most
abdominal surgeries.Cited advantages of peritoneal suturing
are restoration of anatomy, establishment of barrier, reduction
in wound dehiscence, reducing haemorrhage and minimization
of adhesions.2 Choudhary A et al found dense adhesions where
parietal peritoneum was left unsutured during previous surgery,
access to the peritoneal cavity difficult and time consuming. In
contrast to this, where parietal peritoneum was sutured second
surgery was easier, faster, cleaner with few and flimsy adhesions
and recommended routine closure of parietal peritoneum to
reduce adhesion related morbidity and difficult subsequent
surgery.3
Postoperative pain is one of the major discomforts which drives
the caesarean mothers to seek help. Excessive postoperative
pain can cause stimulation of some responses which leads to
increased secretions in the lungs,sluggish bowel movements.
This causes increased use of pain suppressant medicines and
greater stay in hospital.This also delays breast feeding.4 The
numbness around the incision and occasional aches and pains
may last for several months. De Brito Concado T O et al
investigated the influence of anaesthetic and surgical technique
and postoperative analgesia on the onset of chronic pain after
900
International Journal of Contemporary Medical Research
Volume 4 | Issue 4 | April 2017 | ICV (2015): 77.83 | ISSN (Online): 2393-915X; (Print): 2454-7379
www.ijcmr.
three months of caesarean section and concluded that higher
pain scores in the postoperative period were associated with
chronic pain development after three months of caesarean
section. This interferes with mother infant interaction.5
A small change in surgical technique like change of suture
material affects various factors including post-operative pain.
Even in the National Institute of Clinical Excellence (NICE)
guidelines (2011)6, there is no consensus regarding type of
suture material to be used to close the peritoneum.
Very few studies have been done in this part of the country on
these issues, thus this study was performed to find the relation
of type of suture material used for peritoneal closure with post-
operative pain.
The purpose of the study was to observe the effect of closure of
parietal peritoneum in caesarean section by Chromic Catgut and
Polyglactin 910 on postoperative pain.
MATERIAL AND METHODS
This was a hospital based interventional longitudinal study
conducted in a Tertiary Care Hospital from 1st February 2015
for a period of one year. Approval of the Institutional Review
Board was taken prior to the study. 80% study power and alfa
error of 0.05 were used to calculate the sample size, assuming
standard deviation of 1.48 for pain in Visual Analogue Scale7
(VAS) as obtained in the study of Deshpande Hemant et al.8 To
detect a minimum difference of one in VAS scale,20 patients
were recruited in each group which also considered 10% drop
outs.
Primigravida of 18-35 years aged with average Body Mass
Index (BMI) and single live full term pregnancy, who had
caesarean section using spinal anaesthesia, and gave consent to
participate in the study were selected. Anaemic women or those
who had undergone any abdominal surgeries in the past or who
had infection, hypertension or any other medical disease or on
drugs that cause sedation were excluded. Women who had any
intraoperative complications or postpartum haemorrhage were
also excluded from the study.
A written informed consent was taken from all women for the
surgery and to participate in the study. Joel Cohen technique
was used in both the groups to open the abdomen. Parietal
1
Resident, 2Professor, 3Senior Professor, HOD, 5Assistant Professor,
6
Medical Officer, Department of Obst. and Gynae, 4Resident,
Department of Gen Surgery, S.M.S.Medical College, J.L.N.Marg
Jaipur, Rajasthan, India
Corresponding author: Dr.Nupur Hooja, A-29,Lal Bahadur
Nagar,Girdhar Marg, Malviya Nagar, Jaipur-302017, Rajasthan, India
How to cite this article: Sharma Avantika, Hooja Nupur, Rajoria Lata,
Shastri Apoorv, Sharma Megha, Aseri Sapna. Effect on post-operative
pain of suture material used for closure of parietal peritoneum in
caesarean section. International Journal of Contemporary Medical
Research 2017;4(4):900-902.
Avantika, et al. Effect Of Suture Material on Pain

Patient characteristics Group A Group B Statistical significance

(Chromic Catgut) n =20 (Polyglactin910) n =20
Mean age 23.27±3.24 22.90±2.79 P=0.587
(In years +S.D.) Not significant
Gestational age 38.82±1.62 38.24±2.080 P=0.542
(In weeks + S.D.) Not significant
Body Mass Index 21.37+ 1.34 21.56+1.544 P=0.558
(kg/m2) Not significant
Table-1: Patient characteristics

Time since surgery Mean VAS Mean VAS Statistical at 24 hours postoperatively was less when closure of parietal
(hours) score of score of significance peritoneum was done using chromic catgut than with polyglactin
Group A Group B P value 910 and the mean Visual Analogue Scale difference between the
n=20 n=20 two groups was highly significant (Table 2). Thus, the women in
8 hours 9.4±0.75 9.9±0.0.85 0.0567 (NS) the chromic catgut were more comfortable and could breastfeed
16hour 6.4±0.49 7.25±0.44 <0.001(HS) their infant and move about with less discomfort.
24hour 5.05±0.89 7.50±0.51 <0.001(HS) In our study, the mean VAS score was compared between
32 hour 4.45±0.50 4.80±0.41 0.0219(NS) different age groups. Pearson correlation coefficient was used.
40 hour 2.6±0.50 3.25±0.44 <0.001(HS)
The mean VAS score at 24 hours was taken for correlation.
48 hour 2.0±1.0 2.45±0.60 0.0992(NS)
There was no positive correlation of pain score with other
Table-2: Comparison of Mean Visual Analogue Scale Score in the
factors like age (Table 3) and Body Mass Index (Table 4). This
Study Groups
rules out the confounding effect these factors could have had on
VAS pain scores.
Age Mean VAS score at 24hours postoperatively
(years) Group A Group B DISCUSSION
n=20 n=20 In our study,the postoperative pain score was compared when
Mean±SD Mean±SD two suture materials- Chromic Catgut and Polyglactin 910 were
18-22 yrs. 5.10±0.88 7.20±0.42 used for closing the parietal peritoneum in caesarean section.
23-27 yrs. 5.00±0.93 7.86±0.38 Significantly less pain score was observed when Chromic Catgut
>27 yrs. 5.00±1.41 7.67±0.58
was used. This difference was highly significant statistically at
R value -0.077 (NS) 0.4193 (NS)
24hour. Peritoneum being very reactive responds against any
Table-3: Correlation of postoperative VAS score with age.
foreign material and releases pain mediating substances, thus
there is greater postoperative pain.9 Polyglactin 910 is a delayed
Body Mass Mean VAS score at 24hours postoperatively absorbable and synthetic suture material and may be inducing
Index Group A Group B more amount of foreign body reaction, thus causing more pain,
(kg/m2) n=40 N=40 producing greater inflammatory reactions and adhesions.10
Mean±SD Mean±SD
Deshpande H et al (2012)8 also studied the effect of peritoneal
<22 5.27±0.90 7.56±0.512
closure with Chromic Catgut or by polyglycolic acid suture but
>22 4.77±0.83 7.25±0.50
unlike our study, they observed no difference on post-operative
R Value -0.300 (NS) -0.296 (NS)
pain in caesarean section when varying suture material were
Table-4: Correlation of VAS score with BMI.
used.
We observed that though mean VAS score was statistically
peritoneum was sutured with chromic catgut or polyglactin 910
significant in all the age groups between the two suture group,
according to the group allocated. Intraoperative parameters and
there was no significant change in the mean VAS score within
postoperative pain score were noted. Pain was assessed using different age groups. Thus, age had no correlation with the pain
visual analogue scale. score.
STATISTICAL ANALYSIS The VAS score was also compared between two groups of BMI
<22 and >22. Pearson correlation coefficient was used. The
The observations were statistical analysed and significance was
mean VAS score at 24 hours was taken for correlation. Thus,
noted by using unpaired t test or the Chi square test. Significant
BMI had no effect on the mean VAS score.
P value was <0.05.
The strength of our study lies in the fact that it is a single observer
RESULTS study,VAS score was closely noted and it is a statistically well
The study comprised of two groups of twenty women each. validated study.
Women in group A had closure of parietal peritoneum with The study had a few limitations
chromic catgut while in the group B,closure of parietal 1.Sample size of the study was small for the result to be
peritoneum was done with polyglactin 910.Both the groups significant enough to be applicable to the general population.
were comparable regarding mean age,gestational age and Body 2.Sample population was not representative of the general
Mass Index (B.M.I.) (Table 1). population as only primigravida singleton pregnancies were
The pain as measured by mean Visual Analogue Scale score included. All malpresentations except breech and complicated

International Journal of Contemporary Medical Research 901

ISSN (Online): 2393-915X; (Print): 2454-7379 | ICV (2015): 77.83 | Volume 4 | Issue 4 | April 2017
Avantika, et al. Effect Of Suture Material on Pain

pregnancies were excluded from the study. Women with higher

education were more as they were able to comprehend the VAS
score better.
3.Long term follow up was not done, to comment about the
peritoneal adhesions and chronic pelvic pain.
The controversies raised by this study were whether these are
applicable to the general population as well and what is the
sequalae of these in terms of development of adhesions or
pelvic inflammatory disease.
The future research directions could be directed to look into
the controversial issues raised –presence of adhesions in next
caesarean section or development of chronic pelvic pain.
CONCLUSION
To conclude, if the parietal peritoneum in caesarean section
is closed with chromic catgut, it results in less postoperative
pain, resulting in better patient outcome.Chromic catgut is
also significantly more cost effective than Polyglactin 910.
Hence,Chromic catgut suture should be used to close the parietal
peritoneum in caesarean section.
REFERENCES
1. Arias F, Bhide AG, Arulkumaran S, Damania K, Daftary
SN, editors. Practical guide to high risk pregnancy and
delivery. Elsevier Health Sciences; 2012;14.
2. Bamigboye AA, Hofmeyr GJ. Closure versus non-closure
of the peritoneum at caesarean section (Review). Cochrane
Database of Systematic Review. 2007.
3. Choudhary A, Bansal N. Non closure of parietal peritoneum
at cesarean section and adhesion formation. Int J Reprod
Contracept Obstet Gynecol. 2013;2:406-9.
4. Altinbas SK, Cenksoy P, Tapisiz O L, Beydilli G, Yirci B,
Ercan O, Dede S, O. Parietal peritoneal closure versus non-
closure at caesarean section: which technique is feasible to
perform. J Matern Fetal Neonatal Med. 2013;26:1128-31.
5. De Brito Concado TO, Omais M, Ashmawi HA, Torres
ML. Chronic pain after cesarean section. Influence of
anesthetic/surgical technique and postoperative analgesia.
2012;62:762-74.
6. NICE Clinical Guideline National Collaborating Centre for
Women’s and Children’s Health April 2011 RCOG Press
p 20-3.
7. Melzack R, Torgerson WS. On the language of pain.
Anaesthesiology. 1971;34:50-9.
8. Deshpande H, Burute SB, Madkar CS, Dahiya P. The
effect of suturing and nonsuturing of visceral and parietal
peritoneum on postoperative pain in caesarean section. Int
J Pharm Biomed Sci. 2012;3:164-6.
9. Farooq M S, Ayyaz M, Khan W. Non-closure of peritoneum
leads to reduced used of analgesics and less post-operative
pain as compared to the closure of peritoneum in
appendectomy. P J M H S. 2013;7:506-9.
10. Malvasi A, Tinelli A, Farine D, Rahini S, Cavallotti C,
Vergara D, Martignago R, Stark M. Int. J of Gynecology
and Obstetrics. 2009;105:131–5.

Source of Support: Nil; Conflict of Interest: None

Submitted: 29-03-2017; Accepted: 02-05-2017; Published: 09-05-2017

902
International Journal of Contemporary Medical Research
Volume 4 | Issue 4 | April 2017 | ICV (2015): 77.83 | ISSN (Online): 2393-915X; (Print): 2454-7379